ACP news

Racial disparities

A new study has found that higher rates of disease among black Americans may be rooted in a health care system where blacks are treated by different physicians and in poorer facilities than whites.

The study found that only 22% of participating primary care physicians treated 80% of elderly black patients. The study was conducted by researchers at New York's Memorial Sloan-Kettering Cancer Center and the nonprofit Center for Studying Health System Change (HSC).

According to an Aug. 4 HSC press release, physicians treating blacks were less likely to be board-certified than physicians treating whites (77% vs. 86%) and more likely to report problems providing high-level care (28% vs. 19%). Those problems included getting access to high-quality subspecialists and diagnostic imaging, and to nonemergency hospital admissions. Findings appeared in the Aug. 5 New England Journal of Medicine (NEJM).

The study, which included data on more than 4,000 physicians and 43,000 Medicare patients, also found that physicians who treat black patients provide more charity care than doctors treating whites. The study suggests that geography, not racial discrimination, is behind statistics showing that blacks are more likely than whites to die of serious diseases such as cancer and heart disease, suffer from certain chronic diseases, and have problems obtaining preventive care.

Eliminating racial health care disparities is a major goal of the College, which issued a position paper on the topic in 2003.

Clinical news in the headlines

A new study found that one in five asymptomatic patients with type 2 diabetes suffers from "silent" ischemia, with one in 16 having moderate-to-large myocardial perfusion abnormalities.

The ongoing study found that 22% of more than 500 asymptomatic diabetic patients ages 50-75 who underwent stress myocardial perfusion imaging tests had abnormal results, suggesting coronary artery disease. Of the 113 patients with abnormal readings, 83 had myocardial perfusion abnormalities and 30 had other abnormalities such as transient ST-segment depression. The study was published in the August 2004 Diabetes Care from the American Diabetes Association.

Researchers noted that 41% of those patients with "silent" ischemia would not have been screened under current American Diabetes Association guidelines, which recommend screening patients with two or more risk factors.

A recent systematic review concluded that metformin, an antihyperglycemic biguanide drug commonly prescribed for diabetes mellitus, does not increase the risk of lactic acidosis, a sometimes-fatal condition.

The meta-analysis, abstracted in the July-August ACP Journal Club, found no cases of lactic acidosis in a sample of 37,000 patient years of metformin treatment. However, the findings are not statistically incompatible with previous estimates, and it is likely that patients with absolute contraindications would have been excluded from the controlled clinical trials studied. When recorded, metformin and control groups did not differ in mean lactate levels. When metformin was compared with phenformin, mean lactate levels were lower with metformin.

The incidence of lactic acidosis has previously been estimated to be about 3 per 100,000 patient years with an estimated fatality rate of 50%. Risk factors include renal or hepatic insufficiency, heart failure, shock and acidosis.

The study reaffirms that metformin is a safer alternative to its predecessor, phenformin, which was removed from the market in the 1970s because of its association with lactic acidosis. However, this review does not exclude the possibility that patients with renal or hepatic insufficiency, heart failure, shock and acidosis will have their risk of lactic acidosis increased by metformin.

The business of medicine

The CMS announced last week that it will increase payments to acute care hospitals for inpatient services in FY 2005 by about $5 billion. The increases, which were included in last year's Medicare reform legislation, will take effect in October.

The new final rule marks the first time that hospital rate increases will be tied to performance data, according to an Aug. 3 CMS press release. Hospitals reporting quality data will receive a full inflation-adjusted payment increase of 3.3%, while hospitals that fail to submit that data will get only a 2.9% increase. The Aug. 3 Philadelphia Inquirer reported that it is only the third time in 20 years that the CMS has granted a full inflation reimbursement increase.

The final rule contains other changes that will add up to a 6.2% pay increase for rural hospitals. Total payments in FY 2005 to about 3,900 acute care hospitals are projected to be $105 billion, up from $100 billion in 2004.

Access update

A large hospital system agreed last week to provide low-cost care to the uninsured patients it serves in Mississippi and two other states. The announcement came in response to a nationwide spate of lawsuits against mainly nonprofit hospitals, alleging those hospitals don't provide enough discounted care to uninsured patients to earn their tax-exempt status.

According to the Aug. 6 New York Times, the Tupelo, Miss.-based North Mississippi Health Systems is the country's largest rural hospital system. The system agreed to charge only $10 per hospital or clinic visit to uninsured families with incomes of up to $36,000 and to offer 15% to 50% discounts off its Medicare rates to uninsured families earning up to $72,000. The agreement does not affect bills from physicians who admit patients to the system's six hospitals but are not hospital employees.

According to the Nashville Business Journal, North Mississippi is the first hospital chain to announce a settlement, even though it had not yet been sued by the legal coalition bringing suits against nonprofit and for-profit hospital systems. The coalition, which is led by the attorney who brought class-action suits against tobacco companies, has sued more than 300 hospitals in 21 states.

The American Hospital Association has said the suits have no merit, according to the New York Times, but the North Mississippi announcement could influence actions by the country's other 3,000 nonprofit hospitals.

According to the agreement, which is valued at $150 million over 10 years, the system will not place liens on uninsured patients' homes, charge interest on medical debt or bill patients for more than 10% of their family income. Uninsured patients treated in the last three years could have existing bills reduced or forgiven, while those who paid their bills may get refunds.

The agreement allows the system to petition a judge for changes if the new initiative jeopardizes North Mississippi's financial health.

Pfizer Inc. last week rolled out what it claims is the drug industry's most comprehensive discount drug program geared specifically to uninsured Americans.

The company is now offering average savings of 37% off the retail price of its drugs to uninsured families with incomes of less than $45,000 and to individuals earning less than $31,000, according to a company press release. Eligible applicants with higher incomes can save an average of 15%.

The new Pfizer initiative also expands the company's existing free medication programs. The Aug. 4 Philadelphia Inquirer reported that applicants can call Pfizer toll-free at 866-706-2400 to discuss enrollment.

Training programs

In a recent report, the Accreditation Council for Graduate Medical Education (ACGME) said it found widespread compliance with the new resident work hour rules.

The new duty hour standards took effect on July 1, 2003. In its reviews over the past year, the ACGME reported that only 100 programs--out of more than 2,000--received citations for work-hour violations, while only 3% of responding residents surveyed reported working more than 80 hours a week during the previous four weeks, one of the new rules.

According to the report, the accrediting body received 53 complaints from residents about rule violations. Of those complaints, 11 were dismissed and 42 were followed up with actions ranging from requesting compliance progress reports to placing programs on probation.

In addition to limiting the number of weekly hours residents can work averaged over four weeks, the rules include requirements related to call schedules, time off and the number of consecutive hours residents can work.

ACP news

ACP's Oregon chapter is taking part in a new state initiative to educate patients about cost-effective prescription drugs.

The chapter has partnered with the Oregon Medical Association, the Oregon State Pharmacy Association and the AARP Oregon chapter to provide evidence-based research on drugs for high cholesterol, pain, arthritis, urinary incontinence and other conditions. The group wants to cut through biases inherent in drug company advertising to give patients evidence about improving clinical outcomes and saving costs.

AARP Oregon's Web site allows patients to research categories of drugs, brand names, active ingredients and generic equivalents, and get advice on how to discuss drug options with physicians and pharmacists. Research available on the site is state-funded and performed at the Evidence-Based Practice Center of Portland's Oregon Health & Science University.

ACP members can now receive free copies of popular College publications geared to improving practice management for young physicians and identifying key preventive and screening services.

The fifth edition of the "Young Physician Practice Management Survival Handbook" provides useful information on how to set up and manage a practice. The handbook is revised every year to keep it current.

The second edition of the "Pocket Guide to Selected Preventive Services for Adults" covers screening services, clinical guidelines, and counseling and preventive measures including adult immunizations.

Both guides were produced by ACP's Young Physicians Subcommittee, a College advisory committee representing physicians under age 40 or recently out of residency.

Members can download free copies of either publication online. You can also request printed copies by calling 800-523-1546, ext. 2714, or by e-mail.

Test yourself

A 24-year-old woman undergoes routine evaluation. She is pregnant at 12 weeks' gestation. Medical history is notable for homozygous sickle cell anemia (Hb SS). She has had multiple uncomplicated painful crises treated at home with hydration, nonopioid analgesia, and incentive spirometry. Following a physical exam and lab studies, what is the most appropriate management?

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